99100047 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY io o In -�—
CITY OF CUPERTINO BUILDING-ELECTRICAL 1 PERMITNO
BUILDING DIVISION APPLICATIONIPERMIT PLUMBINGMECHANICALSOOOI
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS SANITARY NO. MICATION SUBMITTAL DATE
x - 9g
1 S NAM PHONE CONTRACTOR'S NAME: LIC NO:
NIC CON'1'kOLM
ITF,Cr/IiNCINEIiN: `tel LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG IiLECT PLUMB MEC,H
bC yy6 _ 3351 ❑ ❑ t9t ❑
LICENSED CONTRACT OR:S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby of dna that 1 am licensed under provisions of Chapter 9leommenchtg JOB DESCRIPTION
��Z with Section 70db of Division 3 ofthe Business and Profc„ions Code.and my license is RESIDENTIAL:
Ii O C PERMIT ISSUANCE
Fes.. `` full lbme.andcffca. El STUNT. D KITCHEN REMODEL
<—U 2lwnvc Class Lic.p APPLIANCES-RESIDENTIAL. []ADDITION OPLUMBINGRE-PIPE
h Z W Dae Contractor
ARCHITECT'S DECLARATION ❑MULTI-UNIT DSTRUCFURAL
Z Fp y Z I understand my plans shall be used.,public records PANELS MODIFICATION
OZ—x UPT0200AMPS DINTERIOR El CHIMNEY REPAIR
F 4�W Licensed Professional 201-10KCANIPS IMPROVEMENT E]SWIMMING POOLS
�y,F.; OWNER.BUILDER DECLARATION OVER land AMPS OBATH RIiM013GIAREPAIR ODIih1GLITIGN
C C Q 1 hereby affirm that I am exempt from me Contractor's License Law for the
�S a following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL DOTHER /
1+13
o N which require,s permit to cantonal,alter,improve,demolish,or repair any snucmre ,4 /may
f'LL� 5 put onaitsi....nw.aBn requires the applicant forsuch permit,,fileosignedstatement SPECIAL CIRCUIT/MISC.
W mat he is licensed pursuant m the provisions of the Contmcml,License law(Chapter 9
a�CpC al
(commencing with Section 700(a of Division 3 ofthe Business and Professions Cote)or TEMP.METER OR POLE INST.
thCOMMERCIAL:
1 X m LL at he exempt thee&anr and the basis for the alleged e.nn,aim i.Any vinlatin.of D NEW BLDG/ADDITION D DEMOLITION
Section 9031.5 by any applicant for a permit subjects the applicant to a civil Penalty of POWER DEVICES OTENANT ❑FOOD SERVICE
not more than Eve hundred dollar,(1500).
�Z} SWIMMING POOL ELECTRIC 0THER IMPROVEMENT
6 wi I o the work,the mopmul(it cmpinycm tended or
wugu a,sale
le(See 7 nn.Business
F=G will Jo m......Codes he mm is lmi License L.av does .,apply 1.an.name,
o O D'l'HEiR
Fnot
P.3m a or Pnsfesvions Cale:The Contmitne. License Law does rotapply ,if mvncr of OUTtEfS-SWITCITF3-FIX'I'URF_S
his —a who builds or improves thereon•and war,,rows such wuik intended
,f m through
his two employees,building that such improvements are not iyearofd m offered for NEW RESIUGNI'IAL ELECT it S/1
'.
sale.I_b eventheve the burden
is at he
nonb yemof completforpaeSQ.1-7.FLOOR AREA &SQ.FT.
Vb cr will have the buNen of proving that he Aid ern hnild or improve for pur-
c ,ala).
L as owner of the pmpcny�am exclusively contracting with licensed contractors to TOTAL:
,,n.am t the project(Sec,7011,Hminess and Professions Cale:)the Contractor's Li-
censeLuwdocsndapplymanowncrc property who b.edsor bapnwesthemon,and QTY. PLUMBING PERMIT FEE �j
who summers fm such pmjmts with a conmctor(Q licenseg pursuant to the Contractors /
License Law. t
❑1 nn excm a S . .B&P C lin this rcuvun PERMIT ISSUANCE
If F ALTER-TRAIN&VENT-WATER(EA)
7 fC VALUATION
s %Y/ry///WORKER'S COM PENrjury on DECLARATION RACK FLOW PROTECT DEVICE
a.r1h Ron under petmltyof ofjuryaneofthefollowing Wridwev Co
wom,as pro will forbyneCion37Mfictim of the vert toLahr self-Codensure for Workers Compen-'he URAhYS-Fl.00R.ROOEAREA.COND. STORIES TYPE CONSTRUCTION
work f as .melt his
for by Seddon 37d1 of the Labor Cade,for the ped'urmancc of the
work Tia which this permit i,orker. Iq XTURES-PER'1'RAP
37 I have La will maintain Worker's compensation work
far which
h his or ,i Section
M011olker Luhm Codahm tIhe n,amrmmnnec of ad work forwhichthis permit is issued. GAS-EA.SYSTEM-1 INCSOUTLETS (K:C.GROUP ST APN��
Ca Worker's Cnmpcnsmiun Innvmnw realer and Policy oumhcr are: J !P_
Carrier: Policy No.: I GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMP17NSATION INSURANCE GREASE/INIIUSTRI.WASTE INTERCEPTOR
This section need not be completed if the pemtit is for one huddrial dollan(Slat) BUILDING DIVISION FEES' or less) GREASE TRAP
PLANCH[CK FEE
I crony that in the perfommnce afthe work for which this permit is issued,I,hall SEWER-SANITARY-STORM EA.21(1 FT
not employ any person in any m:mne,so ass et are....subject m me Wnrwa,'Contpen- IiNI RGYTEB'-' �...,��,�
Z cation maws nr cahromia.Dam
O t WATER fRiATER W/VE.YI'/ELF,CIR
Z. Applicant K PIll ITL. s
= NOn'ICI?TOAPPLICANT:
rsafter making thisvikin ,of h Exemption.you,haring WATER SYSTEMn REATING
F” Bsnme whjmnnthe Workers Compensation provi,inn,of he labor Code,you must Sf)IIS FEE II '•I
10 forthwith comply with such provisions ethic permit shallMJcemed revoked. WATER SERVICE M 1999 II �II
7 z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT AID V
V O l hereby affirm that here is a concoction lendmg agency for mm
e perforance of Date Receipt#
the work for which this perad is lvsued(Sec,3097,Civ.C)
Ixndcrs Name Ily
TOTAL:
" U
Lender's Address TOTAL: _
F1 I eco Ry that 1 have read thh.pplicmion and state that the above inhuman an is BUILDING FEE
rA comas,l agree to comply with all city and county ordinances and stale laws relating to QTY. MECHANICAL PERMIT FEE
C.7 Z building concoction.and hereby anthod/e representatives of this city to enter upon the SF.IS MIC 1tiL
tdowe mentioned property for iavpection purposes,
(We)agrw In save,indemnify and keep hurndcss Me City of Cupminn ngaima PERMIT ISSUANCI? ELECTRIC FEE
liabilities,judgments.costs and expenses which may in any way accme against said City ALTERORADDTOMECH.
,,sequence of the gmating of this permit. PLUMBING FEE
APPLIN"UNDERSTANDS AND WILL COMPLY Willi ALL NON-POINT AIR HANDLING UNIT(TO 10,000CPM)
SOU 'E :GULATIONS. / 1 MECHANICAL FEE
I,//\/' lQ 6/ AIR HANDLING UNIT III. ICFM) C(INSTRUCTIONT
ignat sof ApplicaHA7ARDOUS MATERIALS DISCLOSURE •Dam EXHAUST HOOD(W/DUC17 HOUSING MITIGATIONF;
Will the applicant or future building occupant store or handle harardou.v material H17NI'ING UNIT ITO 100,000 BTU)
a,defined by the Cupmino Municipal Code.Chapter 9.12,and the Health and Safety
Calc.Suction 25532(x)? HEATING UNIT(OVER IUB.00f)BTU)
❑Yes 7 N TALO
VENTILATION PAN(SINGLE RESIIII
Will thea applicant or future building t use Una Receipt a
pP dbyutB ea Air Quality
Management
BOILER 100,0006TU1
emit hazardous air contaminants as defined by ee Buy Area Air Quality Manugetrmm TOTAL
Lb.ildi.
El Fl No BOILER-COME(OVER 100.000 BI U)
u real the hxmoi.a,mmerialy rommemcnu under Chapter,695 of the Cali- AIR CONDITIONER ISSUANCE DATF.
h SCfdy Qrmle.Sccfionv 255115.25533 and 25534.1 undersand eat tithe NEW RESIDENTIAL MECU SQ.IT / �
ro eamn0yh.veamnantm it is my respod,ibility to notify Ute occupant re I,which rung t 'o tas'ssnun ofCmificatmodzeg.genI U Hart,
ant TOTAL:
ISSUED BY:
' OFFICE